I am
going to be more active this year, and that includes attending more
yoga classes. Yoga has meant the world to me, because it has allowed
me to play golf and be pain free (neck and back) most of the time. I
have reported on yoga and shown most of the standard yoga positions
and which muscle groups they affect in previous reports (see subject
index). Some of them came from:
www.yoga.com/poses

Another comprehensive discussion on the medical benefits of yoga
is also available through a national website writtenbyJenn Miller.
Please click on this website to motivate you to incorporate yoga
into your day. It will be the best New Year’s Resolution you ever
make.

I remind you that any medical information provided in these
reports is just that…information
only!!Not
medical advice!!
I am not your doctor, and decisions about your health require
consultation with your trusted personal physicians and consultants.

The information I provide you is to empower you with knowledge,
and I have repeatedly asked you to be the team leader for your OWN
healthcare concerns. You should never act on anything you read in
these reports. I have encouraged you to seek the advice of your
physicians regarding health issues. Feel free to share this
information with family and friends, but remind them about this
being informational only. You must be proactive the current medical
environment.

Don’t settle for a visit to your doctor without them giving you
complete information about your illness, the options for treatment,
instructions for care, possible side effects to look for, and plans
for follow up. Be sure the prescriptions you take are accurate
(pharmacies make mistakes) and always take your meds as prescribed.
The more you know, the better your care will be, because your doctor
will sense you are informed and expect more out of them. Always
write down your questions before going for a visit. Get copies of
medical tests and if there is an electronic medical record, learn to
use it.

The FDA has approved a monthly
injection for treatment of opioid (and alcohol) addiction
disorder (moderate to severe) based on a study that reported a
40% abstinence rate compared to a
placebo (5%).This is a big
step in the right direction in addressing the treatment of opioid
and alcohol addiction. These are medical illnesses and need to be
treated as such.

The medication is a sustained release
naltroxone (380 mg) given intramuscular every 4 weeks. This
medication (oral form) was approved in 1984 for opioid addiction and
2006 for alcohol dependence. It blocks the pleasure center in the
brain when these substances are used and reduces cravings. It is now
available as a monthly injection, which prevents daily intake and
manipulation of the dose schedule. The oral form was not very
successful because of compliance by addicts, and it is also too easy
to skip doses.

7-not recommended for older and very young patients, because there
are no studies that have been carred out on elderly patients or
those under 18 years of age.

Mild nausea for 2-3 days is the most common side effect.

Ideal candidates are those in a
comprehensive treatment plan,
understand this is not a substitute for a treatment plan, and who is
willing to abstain from these substances for 7-10 days and undergo
detox if needed prior to injections. Patients also must understand
that if they use opioids, they may overdose at lower doses of opioid
since these patients have had the drug out of their system for a
time.

I suspect there will be a limited number of physicians using this
medication for awhile, so ask your doctor or contact a alcohol and
drug rehabilitation center.

Writing about this disorder has personal and professional
significance to me, because while I was a head and neck surgeon for
30 years in Florida at age 50, I also had the misfortune of
developing a base of tongue cancer in 1991. I was treated with twice
a day radiation therapy and developed a severe dry mouth from the
radiation to my throat and neck including the saliva glands, which
were in the field of treatment. Since it is permenant, I still
suffer to this day from dry mouth and have had multiple dental
complications even in the face of aggressive dental prophylaxis.

It is such an impediment to have to take a sip of water with every
bite of food just to have enough fluid in my mouth to mix with food
to be able to adequately chew and swallow. Without fluid or some
substitute in my mouth, my speech becomes impaired. These are
classic things that are taken for granted until they are taken away
from you.

Hundreds of medications, cancer treatments, and salivary gland
diseases all can cause what is technically called
xerostomia (pronounced zero-stomia).
This disorder is a serious cause of dental disease including
periodontal disease and dental decay.

A. Dry mouth syndrome has all or some of these side effects and
potential consequences:

Inflammation of the salivary glands can also reduce saliva. They
include diseases such as *Mikulicz disease, **Sjogren’s syndrome,
salivary stones that can block the parotid gland ducts, and tumors
of the glands that may present with a dry mouth and other local
symptoms. These diseases must be treated. An ear, nose, and throat
surgeon is specially trained to care for these problems.

Salivary glands include pairs
of glands: parotid, submandibular, and
sublingual as seen in the drawing below.
Mikulicz disease and Sjogren’ Syndrome are diseases of the salivary
glands (and also tear glands in Sjogren’s).

C. Content of Saliva—its importance and function of each
component

Saliva is comprised of 99.5% water,
plus electrolytes (sodium,
potassium, etc.), mucus,
white blood cells,
proteins, enzymes (amylase and
lipase), and antimicrobial agents
such as immunoglobulins (IgA), and lysozymes. These enzymes digest
proteins and sugars in the mouth that are critical in preventing
tooth decay.

a) Water content

The water component of saliva is
essential in rinsing food off the surface of the teeth (including
the mucus content of saliva) which allows food to glide over the
oral mucosa and easily down the throat. Without it, it is necessary
to take a sip of fluid with each bite of food to substitute what is
normally present—an extremely annoying issue for thousands of
sufferers. These can be a problem during
chemotherapy and alter taste.

b) The mucus content of
saliva—proteins and enzymes

Salivary mucus contains valuable
proteins and immune products (IgA) that help loosen the
bacteria from the teeth and gum surface. They also neutralize
viruses, bacteria, and enzyme toxins. The
enzymes in mucus (amylase and lipase)
help destroy the bacteria and sugars that feed the bacteria that
allow dental decay. Without this protection, acceleration of the
tooth decay process occurs.

Salivary liquid allows food to flow smoothly over the tongue and
down the throat as well. Without this function, it is very easy to
choke on food during swallowing.

Another important function of saliva is to assist with taste.

c) The buffering(maintaining a
normal ph) effect of saliva

Saliva also provides a buffer
(neutralization) for the pH (acid content) of the mouth. The average
pH of saliva is 6-7, and without adequate salive, the pH can drop to
5.5 or lower allowing demineralization of the enamel of the teeth,
the hard outer protective lining of teeth. The buffering
(neutralizing) of these acids in the mouth also prevents an
environment that bacteria thrive in.

Saliva also contains urea,
another buffer product of saliva, which breaks down
ammonia released as a byproduct
of bacteria, which can be toxic to the gums.

d) Biofilm thickness of saliva

Even the thickness of the saliva on the teeth is important for
dental health. It is called the biofilm
thickness. The thinner the biofilm, the greater risk for
dental and gum disease.

e) Fluoride carried by saliva

Saliva is critical in maintaining the physical integrity of tooth
enamel in many ways including carrying
fluoride in saliva necessary for stabilizing the dental
minerals necessary for the health of teeth. Ingested fluoride (from
fluoridated water, toothpaste, rinses, etc.) is concentrated in
saliva and helps protect the teeth.

f) Saliva’s value in healing

The overall content of saliva also plays a role in healing oral
injuries and diseases such as canker sores. Without saliva, a
negative environment is set up for dental disease.

D. Sugar and tooth decay

Sugars are an integral
part of the tooth decay process. Bacteria feed off many sugars and
other nutrients that coat the teeth. Tooth brushing eliminates some
of these chemicals, as does irrigations and flossing between the
teeth. I personally favor dental irrigators in addition to flossing
to dislodge food missed by flossing.

Xylitol

The sugar, xylitol, cannot be
used by bacteria, and therefore, is commonly used in chewing gum
suitable for those with a dry mouth. It would be my wish that sugar-
containing chewing gums be taken off the market, and be replaced
with xylitol, because of the damaging effect on the teeth even in
those with normal saliva. Chewing gum can stimulate saliva, so a
xylitol-containing chewing gum is a good idea.
5-10mg per day of xylitol is necessary
to be effective in fighting tooth decay. Read the labels on
xylitol containing products to be sure this amount is consumed daily.

According to several sources, there are over 500
medications that can affect the production of normal saliva.
Some of the common groups of medications
are antidepressants, antihypertensive drugs, anxiety drugs
(benzodiazepines), antihistamines and decongestants for allergy,
reflux meds (proton pump inhibitors), opioids, cannabinoids
(marijuana), and diuretics. Discuss with your physician and dentist
about stopping a drug or drugs to see if dryness of the mouth will
improve. Do not stop a prescribed
medication without medical supervision and talk to your dentist.

F. Conditions that cause dry mouth

There are many medical conditions that affect salivary flow and
volume. These diseases include salivary
diseases (Mikulicz syndrome, Sjogrens syndrome, etc.),
Alzheimer’ disease, Parkinson’s disease, diabetes, rheumatoid
arthritis, mumps, and even hypertension. Nursing homes are full of
dehydrated people with dry mouths. For a complete list, check on the
internet.

G. Treatment for Dry Mouth

For those who develop dry mouth, a dentist is imperative in
assessing any dental or gum damage. If a person is a
mouth breather (which aggravates
a dry mouth), an evaluation for causes of
nasal obstruction is recommended,
and if a snorer, seek an evaluation for
obstructive sleep apnea. If on CPAP for apnea, be sure a
humidifier is added to the machine.

There is no cure for dry mouth
unless a medication can be stopped. Otherwise, it is a matter of
coping with the disability and using optimal hydration, oral
lubricants, and preventing dental diseases.

H. For patients undergoing radiation therapy

If a patient is to undergo radiation of the head and neck, it is
critical to see an experienced dentist familiar with radiation and
head and neck cancer. Pre-radiation consultation is a necessity. An
intensive plan of dental prophylaxis is
necessary. If there are dental issues prior to radiation,
they must be treated. If there is severe dental and gum disease,
extractions may be necessary. Follow up during and after radiation
is critical for life! Because of radiation dental decay over the
first few years after treatment, I have had to have every tooth in
my mouth crowned (over $30,000).

The current technique of radiation is much better than I had in
1991, and at least some of the salivary tissue is spared with
current radiation techniques which should lessen the dry mouth
problem. Make no mistake, if teeth are radiated, there will be
consequences regardless of the amount of salivary flow.

Because the mouth will be extremely sensitive and painful (mucositis)
while undergoing radiation (and certain chemo agents), the use of a
dental irrigator with proper additives will clean the teeth more
efficiently than brushing. Rinses with fluoride will likely be
recommended as well. There are solutions called “magic
mouth wash” that may be recommended during the treatment
phase and for an extended time after treatment. These mouth washes
contain antibacterial, antifungal, cortisone, fluoride, and other
ingredients to assist in cleansing a painful mouth from radiation
and chemo.

I. Foods and liquids to avoid

Alcohol, caffeine, certain fruits (can burn the mouth), mouth wash
containing any alcohol, tobacco, hot sauces, and marijuana will
aggravate a dry mouth. Eating bread can be a challenge and
swallowing should be performed with extreme caution to prevent
choking.

J. Treatment options for gum disease and dry mouth

Since a dry mouth may lead to dental decay, gum disease and
periodontitis, the treatment is the same regardless of the cause of
a persistent dry mouth. Prevention is always the best and any
regimen must see a dentist and dental hygienist for routine
cleanings and examination (preferably 3-4 times per year). Early
intervention of dental issues is a must.

Here are some options for treatment:

1) Sialogogues (drugs that
stimulate saliva)

These products are parasympathomimetic drugs (i.e. pilocarpine-Salagen
and Evoxac), but there are side effects such as flushing of
the skin and sweating (sweat glands have the same nerves as salivary
glands) that may be unacceptable. They actually stimulate the nerves
that innervate the salivary glands. If the salivary glands are
destroyed by disease or radiation, these stimulants will be
unsuccessful.

2) Chewing gum containing
xylitol. As mentioned above, this sugar cannot be used as an
energy source by bacteria and therefore is safe to chew. It does
stimulate saliva to some extent, and the act of chewing massages the
salivary glands to squeeze saliva out (if some saliva is still
present).

Be sure the chewing gum contains a maximum amount to (5-10 mg per
day) of xylitol.

There
are many products that contain xylitol, and this is just one of
them. Do the research and make good choices for you and your family.

3) Lozenges, rinses, sprays

There are many products available over the counter or online. Oral
sprays or gels are my preference. Patients often must carry a water
bottle for sips to combat dryness. I am never without a water
source.

4) Flossing and irrigators

When there is poor saliva volume, the teeth are dry and food and
bacteria can more easily stick to the teeth. Flossing after every
meal is the best technique to combat
plaque (bacteria that stick to teeth), however, dental
irrigators will assist in the process. Using both might be optimal.
Dental irrigators will clean in the crevices where floss cannot
reach especially just under the tooth-gum line. They are essential
when the patient’s mouth is too sore to tolerate a toothbrush.

5) Hydration is incredibly
important. Patients without saliva are dehydrated. Saliva produces
one liter of fluid per 24 hours. At least 8-10 glasses of water per
day is suggested. If a person’s urine is dark yellow, the person is
dehydrated.

6) Fluoride toothpaste/gel, toothbrushes

Why is fluoride important? It
is nature’s tooth decay fighter. It makes the enamel of the teeth
stronger. It can also help rebuild enamel by remineralizing the
tooth’s surface. By taking fluoride into the body through foods and
water (fluoridated water), it is secreted in normal saliva giving
continuous benefit to the health of teeth. Studies show that it
reduces the risk of cavities by 25% in children and adults. Tooth
paste has been fortified with fluoride since 1960 and has been
responsible for a major reduction in dental decay.

Brushing with a fluoride containing toothpaste and flossing after
every meal is very important and its importance must not minimized.

Most people rinse their mouth out after brushing which eliminates
a significant amount of fluoride in the toothpaste. It is
recommended to spit part of the toothpaste out and rinse the tongue
but leave a residual amount of paste on the teeth for prolonged
protection. Toothpaste containing prescription-strength fluoride
should not be swallowed to prevent toxicity. A person should abstain
from fluid or food intake for as long as possible after brushing to
prolong this fluoride residue on the teeth. In between meal treats
(especially with sugar) will continually challenge the teeth to
decay.

An electric rotary/oscillating
toothbrush is superior to a regular toothbrush in getting rid
of plaque, and always using a soft brush to prevent excessive
abrasion of the enamel regardless of type.

Do not share toothbrushes!! Ever!!! Change toothbrushes at least
every 3 months.

Dentists often prescribe fluoride toothpaste or gel containing
1.1% fluoride as additional help
for those who do not have adequate saliva or for those at increased
risk of decay.

Fluoride gel treatments performed in the dentist’s office may be
recommended. It is common to prescribe either fluoride gel trays at
night at bedtime or prescription fluoride toothpaste at bedtime for
more serious cases. A minimum should be swallowed to prevent
fluorosis, a condition of
mottling of the enamel, much more common in children.

Especially for those with a dry mouth and/or are mouth breathers, a
cool mist humidifier by the
bedside at night is very helpful. As mentioned above, if a person
has obstructive sleep apnea, the addition of a
humidifier connected to their CPAP
machine is an important help. Coating the mouth at bedtime
with a dry mouth lubricant, gel, or spray described below also is
helpful.

8) Product reference for Dry Mouth
Syndrome

A
dear friend of mine who is an internationally known speaker and
motivator for oral cancer survivors, Eva Grayziel, is an oral cancer
survivor herself (like me), was kind enough to share a fantastic
poster with all of the products available online or in the
pharmacies. Judy Bendit, RDH, was coauthor of this poster. Thank you
both!

Eva is a big supporter of the Oral
Cancer Foundation and is present in many of their events
around the nation.

About 5-10% of all cancers have genetic
mutations. Only some of the genetic mutations have been
discovered and many are yet to be discovered. Screening for these
syndromes is quite important for families who are at higher risk for
developing cancer often earlier in their lives before standard
screening is recommended. These syndromes point to the importance of
knowing a person’s family history. It also points to the need for
expert genetic counseling, which
has created a flood of patients seeking their expertise and genetic
counselors are in great demand and are scarce.

There are many internet sites that offer genetic testing, and I
have enumerated what genetic mutations are commonly offered. When
there is a genetic abnormality(s) on a report, this creates a need
for counseling to decide a course of action for the family.

BRCA suppressor gene mutations

This genetic abnormality in the BRCA 1 and 2 gene mutation (Breast
Cancer) creates a high risk of breast (85%) and ovarian cancer (55%)
in families. This was brought to the attention of the public by
actress Anjolie Jolie. I have discussed this in detail. Click on

Until
recently it was not known to also be a risk factor for
men. A study cited on Medpage (an
online medical journal) that men are 8 times more likely to develop
certain cancers especially melanoma and prostate cancer if BRCA
positive. But now other cancers have been added including
colon, pancreatic, and male breast
cancer.

17% of the men in this study who were positive for the BRCA gene
mutation developed cancer, many at an earlier age than the general
population.

The American Urological Association has reported that as high as
20% of men with prostate cancer exhibited some kind of DNA mutation.

6% of Israeli Ashkenazi Jewsare carriers for the BRCA gene mutation, mostly BRCA 2. As
this issue has become more important, the University of Michigan has
opened a BRCA gene mutation for men
to screen them more frequently and earlier than normally
recommended.

There also appears to be a higher incidence of BRCA gene mutations
in metastatic cancers, implying
that the cancers that spread may be more aggressive because of the
genetics.

The bottom line is this: if a
man has a positive family history for breast cancer, they should
seek consultation to have a genetic study. There is even a
prostatic gene mutation panel
that can be ordered. Just having a genetic mutation alone must be
correlated with other familial factors.

General population screening is not
recommended, however, in groups such as just described, it
certainly should be considered if certain cancers exist in families.

Today, oncologists order genetic
profiling to direct their treatment (not to screen for
cancer) since these genetic abnormalities can predict response to
certain treatments. In clinical trials and advancing disease,
testing has become a more important factor in determining choice for
treatment.

Medpage, May 15, 2017

Lynch Syndrome

These
families have a non-polyposis syndrome creating a higher risk for
colon and uterine cancer.

Cowden Syndrome

This syndrome is characterized by having non-cancerous growths in
the skin and mucous membranes (hamartomas). These families have a
genetic mutation (PTEN) causing an increase risk of breast, thyroid,
and uterus cancer.

Other Syndromes

Neurofibromatosis
(Von Recklinghausen) causes tumors along the sheath of nerves in the
body and brain.

Patients who have 2 or more family members with certain cancers
should consider genetic counseling before going online and getting
tested for genetic mutations. Large cancer centers usually provide
this kind of testing and have the greatest experience in guiding
patients.

The North American Menopausal Society has revised their
2012 guidelines for estrogen therapy for women who become
pre-menopausal with symptoms. This discussion with your doctor
should take place as soon as menstrual periods become erratic,
symptoms appear, or there are medical reasons for an induced
menopause.

Note that last comment!
There has been concern by some women for continuing estrogen therapy
for extended periods of time. The risk/benefit discussion must
always be understood before going forward with any new guidelines
discussed with a patient’s doctor.

There are many disease states that create no symptoms until a
complication occurs that could be fatal. Atrial fibrillation is an
example in some cases.

A recent study reported on 6011 patients and
69% were without any symptoms and
most did not know they had atrial fibrillation.
Those asymptomatic patients were twice
as likely to have a stroke
(15%) compared to those who had symptoms and were under treatment.
TIAs (transient ischemic attacks) occurred more often (19%) vs. 10%
in the symptomatic group.

This suggests the argument for early
detection with routine EKGs and physical exams in older
people. A doctor can also hear the rhythm abnormality with a
stethoscope. The reason that A-Fib patients with symptoms will have
fewer complications is because they are on anticoagulant therapy to
prevent emboli from the heart sending a clot to the brain causing a
stoke.

Symptoms of atrial fibrillation
include palpitations, lightheadedness, dizziness, general fatigue,
rapid or irregular heartbeat, fluttering in the chest, chest
pressure, and faintness. All of these could be very mild and if a
patient ignores them, a patient is putting themselves at unnecessary
risk.

Patients may start with intermittent A-Fib, and therefore be
missed on exams and tests by doctors.

Patients also need to know the symptoms of a TIA and or stroke.
Symptoms of a TIA are the same but dissipate.

Social anxiety disorder is a subtype of generalized anxiety and is
very common. Most of us have had experience with getting nervous
before a speech, a test, a sport activity, etc. However, when that
anxiety is intense and keeps one from performing well, it must be
addressed. People who have a fear of being scrutinized by others to
an excess, and when fear of failure is not controllable, counselling
should be considered.

Social anxiety disorder affects up to
13% of the population and is characterized by an intense fear
of being viewed negatively. Those who have this disorder are at
increased risk for generalized
depression and substance abuse.

Unfortunately, most people would not
seek help for such a problem. This is one of those disorders
that must be brought up by the physician when a patient seeks help
for a co-existing condition such as depression, panic attacks, etc.

Since time is limited when seeing a primary care physician, it is
incumbent for the patient to bring up such issues as social anxiety,
or it will be more difficult to treat depression, etc.

Social anxiety disorder begins at an early age (about
13 years of age) but is often overlooked for years.

There are three common co-existing conditions that should be
understood—1) depression 2) substance
abuse potential 3) avoidant personality disorder. How many
teenagers avoid contact, stay in their rooms, and fear being judged
by others? Impaired social skills, thoughts of suicide, and
avoidance of personal relationships, and difficulty in school or
work are not uncommon. When asked, over a third of these people will
admit to these issues. They are often described as shy.

Genetic and environmental factors are common. If parents suffer
from this disorder, their children are at higher risk.
Neurobiologic abnormalities
(circuit dysfunction in certain parts of the brain having to do with
serotonin production) are suggested as the cause, as are many
disorders such as depression, general anxiety, etc. Further study is
needed in the area.

Key screening questions must be
asked by the physician, the parent, the caregiver, or the spouse.

1) Do you avoid social situations and activities?

2) Are you fearful or embarrassed in social situations?

3) Do you take illicit drugs or drink alcohol to feel more normal
and acceptable in social situations?

4) Do you feel depressed? (frequently depression will mask social
anxiety disorder).

5) What are friends saying on social media?

Treatment

Cognitive psychotherapy is the
first-line of treatment with about 50-65% success and longer lasting
results. However, since most patients refuse formal therapy, as in
most of the less severe psychological disorders, primary care
physicians are faced with treating most of these patients with
anti-depressants (SSRIs) and
benzodiazepines (Xanax, Valium,
etc.). The results may be faster, but do not last as long as
cognitive psychotherapy. Attempts still need to be made to get
patients to see a counselor (psychologist, psychiatrist), especially
if the symptoms continue or recur. Coordination with school
authorities and counselors is critical.

12 million office visits per year
in the U.S. occur annually because of wax impactions in the ear
causing a variety of issues including hearing loss, a sensation of
fullness, itching, popping, infection, and even izziness if pressed
against the eardrum. Between Medicaid and Medicare, reimbursements
of $46 million annually are paid for removal of wax impactions. 1/3rd
to 2/3rd of nursing home patients who are over 65 have
this problem and with superimposed impaired hearing, wax impactions
are a serious issue.

Ear wax is created by skin cells in the ear canal sloughing off
which accumulates in the canal are prevented from migrating out of
the ear. There is normal migration of the wax out of the canal, and
can be felt as it comes out in small amounts at a time, but using
q-tips can push the wax further into the ear canal and create an
impaction.

Keeping water out of the ear is wise so that the wax does not mix
with it and swell the wax blocking the canal even more.

Before performing any home remedy, it is suggested that the
primary care doctor examines the ears to see if wax is present and
the extent. Most primary doctors will irrigate the wax out if asked.
It is important to know if there is a history of a hole in the
eardrum (perforation), recurrent swimmer’s ear, or other known
pathologic processes. If they are not equipped to clean ear wax,
consult an ENT doctor.

Home Remedies (read the
instructions in the package insert carefully). A person must realize
that they make the situation worse, if it happens, seek immediate
help before an infection sets up.

Bulb irrigation with drops to liquefy the wax

Murine has a good
kit. If you chose to use this system or other similar kits, warm the
drops slightly before placing in the ear. Fill the canal and place a
piece of cotton gently in the outer ear canal to prevent the drops
from spilling out. Wait 20 minutes and irrigate with a full bulb
using a combination of warm water and vinegar (3/4 cup of warm water
added to ¼ cup of warmed white vinegar). With the ear turned down
(not up), irrigate in an upward stream to allow the wax to come out.
If it does not in 2-3 attempts, I would suggest a consult with your
doctor.

Never use cotton tips as they will push the wax deeper into the ear
canal.

Never put anything bigger than your elbow in your ear!!!

Do not
use a forceful irrigation like a water pik. I recently saw a screw
like applicator (below) to clean the ear wax and I have to condemn
it.

As an ENT surgeon for 30 years, I have seen many injuries to the ear
canal from home remedies, so don’t be foolish. It is best to see the
doctor. Seeing an ENT physician is the best choice, because they
have instruments, irrigators, and binocular visual instruments, and
the most experience.

These suggestions should be discussed with your doctor before
proceeding. This is just information, and not meant to be followed
without approval of your personal doctor.

This disease is also called bladder pain syndrome
characterized by pain, pressure, and discomfort of the area above
the pubic bone in the lower abdomen and perineum associated with the
usual urinary tract symptoms of an infection (frequency, urgency,
nocturia, blood in the urine, etc.) and painful intercourse. Women
have this disease 10:1. 3-7% of Americans have this diagnosis.

This disease is often associated with
other pain syndromes such as allergies, irritable bowel
syndrome, fibromyalgia, etc. including depression and poor quality
of life.

The cause of this disease is not well understood, however,
autoimmunity is suggested.

Although cystoscopy is not
required to make the diagnosis, it is necessary to rule out other
causes of these symptoms, including infection, prolapse of the
pelvic structures, tumors, stones, and other pelvic pathology.
Urological consultation should be considered if this disorder
continues for several weeks without improvement.

Cystoscopy findings

Scarring and small multiple hemorrhages are found frequently.

First line therapies-

Patient education regarding this disorder to understand the issues
and cooperate with several symptomatic measures, including
hydration, using pyridium to relieve pain, bladder training,
relaxation techniques, and other coping measures.

Second line therapies-

Amitryptyline-a
tricyclic antidepressant has helped in many cases helping pain and
urgency symptoms.

Cimetidine-a
histamine receptor antagonist seems to help with pain and nocturia.
400 mg twice a day is recommended.

Hydroxyzine-(Vistaril, Atarax)-this
is an antihistamine with sedating characteristics, which may its
main feature, especially if taken at night.

PPS-Pentasanpolysulfate sodium-(Elmiron)-This
is the only FDA approved drug for bladder pain from this disorder.
100mg three times a day is recommended.

Operative treatments-

50% DMSO (dumethylsulfoxide) is
the only FDA approved medication that can be instilled into the
bladder. Heparin (anticoagulant)
and hydrocortisone, and
lidocaine derivatives can be
instilled simultaneously. These treatments are performed every 1-2
weeks for 6-8 weeks.

This is a chronic condition that will need to be followed long
term.

This completes the January, 2018 report. Next month, the February
subjects will be:

1) Treatment of prostate cancer versus close observation

2) Infection risks in patients with cardiac implantable devices

3) Questions to ask at the time of discharge from the hospital

4) e-cigarettes and smoking cessation success-an update

5) Cancer survivorship series—second cancers and continued pain
after treatment